A nurse is caring for four clients. Which of the following clients is at the greatest risk for falling?

A client who has diminished vision ambulating in well-lit areas

A client who received a diuretic 30 min ago

A client who requires assistance with ambulation

A client who had a tonic-clonic seizure 2 hr ago

Answer and Explanation

The Correct Answer is D

A.   A client with diminished vision ambulating in well-lit areas may be at risk for falling but is not at the greatest risk among the options provided.
B.   A client who received a diuretic 30 min ago may experience orthostatic hypotension, which can increase the risk of falling, but it is not the highest risk.
C.   A client who requires assistance with ambulation is generally at a lower risk than a client who has recently experienced a tonic-clonic seizure.
D.   A client who had a tonic-clonic seizure 2 hr ago is at the greatest risk for falling due to potential residual weakness, disorientation, or postictal state following the seizure.

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Correct Answer is C

Explanation

A. 2+ pitting edema is not a contraindication to cold application; in fact, cold application can help reduce edema.
B. A 7.5 cm (3 in) diameter bruise on the ankle is not a contraindication to cold application; cold can help reduce swelling and alleviate pain.
C. Capillary refill of 4 seconds suggests compromised blood flow, and cold application may further impair circulation. It is a contraindication.
D. Warts on the affected ankle are not a contraindication to cold application.

A. "I will wear cotton socks with my shoes." B. "I will cut my nails so they are rounded at the corners." C. "I will use a mirror to inspect my feet daily." D. "I will buy my shoes late in the afternoon."

Correct Answer is B

Explanation

A. Wearing cotton socks is appropriate as they allow for better air circulation.
B. Cutting nails rounded at the corners can lead to ingrown toenails, which is not recommended for individuals with diabetes.
C. Using a mirror for daily foot inspection is a good practice to identify any issues early.

D. Buying shoes late in the afternoon accounts for any swelling that may occur during the day, which is a suitable practice for individuals with diabetes.

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A nurse is caring for four clients. Which of the following clients is at the greatest risk for falling?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?

Correct Answer is C

Explanation

A nurse is caring for a client who has diabetes mellitus. Which of the following statements by the client indicates a need for further teaching about diabetic foot care?

Correct Answer is B

Explanation

A parish nurse is developing a program of educational sessions to meet the needs of the older adults in the congregation. Which of the following is the best approach to enhance development of suitable programs?

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